- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.73 / $2,728.73 / $3,274.48
| Facility | | $2,728.73 | $2,728.73 | $3,274.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.52 / $2,117.42 / $2,728.73
| Professional | | $1,652.52 | $2,117.42 | $2,728.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,846.18 / $4,846.18 / $5,744.67
| Facility | | $4,846.18 | $4,846.18 | $5,744.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.71 / $2,260.71 / $2,361.41
| Professional | | $2,260.71 | $2,260.71 | $2,361.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $2,717.61
| Facility | | $2,717.61 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $1,983.86 / $2,799.14
| Professional | | $1,983.86 | $1,983.86 | $2,799.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,923.74 / $3,923.74 / $12,110.62
| Professional | | $3,923.74 | $3,923.74 | $12,110.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.81 / $2,417.71 / $2,870.73
| Professional | | $1,611.81 | $2,417.71 | $2,870.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,629.64 / $3,992.60 / $5,081.50
| Professional | | $3,629.64 | $3,992.60 | $5,081.50 |